School-Based Mental Health in Canada: A Final Report

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1 School-Based Mental Health in Canada: A Final Report School-Based Mental Health and Substance Abuse Consortium September, 2013

2 THE SBMHSA CONSORTIUM The School-Based Mental Health and Substance Abuse (SBMHSA) Consortium is a 40-member team of leading researchers, practitioners, and mobilizers involved in school mental health in Canada. Led by the Ontario Centre of Excellence for Child and Youth Mental Health, membership reaches into upwards of 60 Canadian organizations and networks. Ontario Centre of Excellence for Child & Youth Mental Health B.C. Mental Health & Addiction Services B.C. Principals & Vice Principals Association Bluewater DSB Canadian Association of Principals Canadian Association of School Administrators Canadian Association for School Health Canadian Council on Learning Canadian Teachers Federation Centre for Addictions Research of B.C. Council of Ontario Directors of Education Dalhousie University Directions EPRG University of Calgary Hamilton-Wentworth DSB Hospital for Sick Children IWK Health Centre McMaster University Offord Centre for Child Studies Ontario Healthy Schools Coalition PrevNet Queen s University Rocky View School Division The New Mentality University of Ottawa University of Prince Edward Island York Region District School Board York University With support from the Mental Health Commission of Canada, the SBMHSA Consortium synthesized information from a variety of sources to determine the current state of school-based mental health in Canada. Findings from a synthesis of the research literature scan of nominated best practices and national survey of schools and school boards are summarized in this final report. Recommendations for research, policy and practice in school mental health are provided. This report was prepared by the School-Based Mental Health and Substance Abuse Consortium, as commissioned by the former Child and Youth Advisory Committee of the Mental Health Commission of Canada (MHCC). While the MHCC shares the commitment that identifying youth at risk and intervening as early as possible improves life trajectories and reduces the prevalence of mental health problems and illnesses in adulthood, the views expressed herein do not necessarily represent the position of the MHCC or Health Canada. Production of this document is made possible through a financial contribution from Health Canada.

3 Table of Contents CONTEXT AND PROJECT RATIONALE... 1 PROJECT BACKGROUND... 3 KEY FINDINGS... 5 Research Synthesis... 5 Mental Health Promotion... 5 Prevention Programs...6 Intervention and Care... 7 Scan of Nominated Best Practices...8 Scan Development, Recruitment and Administration...8 Scan Demographics...8 Scan Findings...9 National Survey Survey Development, Recruitment, and Administration Survey Demographics Survey Findings...12 Knowledge Translation and Exchange...13 Exploration...13 Early Engagement...13 KTE Experimentation...13 KTE Methods Translation Reporting RECOMMENDATIONS FOR ACTION...15 REFERENCES... 16

4 CONTEXT AND PROJECT RATIONALE Child and youth mental health problems are prevalent Studies suggest that as many as 14-25% (over 800,000 in Canada) of children and youth experience significant mental health issues (Waddell, Shepherd, Chen, & Boyle, 2013; Boyle & Georgiades, 2009; Canadian Institute for Health Information, 2009; Waddell, Offord, Shepherd, Hua, & McEwan, 2002). Most mental health problems can be detected prior to the age of 24, and 50% of these difficulties surface before the age of 14 (Kessler, Berglund, Demler, Jin & Walters, 2005). Mental health difficulties contribute to problems with achievement and relationships at school (Chan, Zadeh, Jhang & Mak, 2008; Kessler, Foster, Saunders, & Stang, 1995). In severe cases, they prevent students from regularly attending class, but more often students simply struggle with these problems on a daily basis, leading to further social and academic functioning concerns. Many children and youth with mental health problems will not receive intervention Most children will not receive treatment for mental health difficulties (Offord et al., 1987a; Rohde, Lewinsohn & Seeley, 1991; Waddell et al., 2013). Social stigma associated with mental health problems deters many youth from seeking help from community professionals (Manion, Davidson, Clark, Norris, & Brandon, 1997; Schachter et al., 2008). Problems with access and availability of resources further limit mental health service use amongst children and families (Kirby & Keon, 2006). Given the high prevalence of mental health problems, and the relatively low rates of community service use, it is important to consider alternative sites and methods for promoting the social-emotional wellbeing of Canada s young people. Schools can promote positive mental health, identify and intervene early to prevent the onset of problems, and respond to children and youth in distress Given that children and youth spend a substantial part of each day within the school setting, these communities become a natural and important venue for mental health service delivery (National Research Council and Institute of Medicine, 2009; WHO, 1994). Senators Kirby and Keon state that this platform for mental health promotion should be recognized. In fact, development of the school as a site for the effective delivery of mental health services is essential (Kirby & Keon, 2006, p. 138). The recently released Mental Health Strategy for Canada is explicit in highlighting the importance of schools for universal mental health promotion, and stigma reduction, as well as for early recognition of mental health problems (Mental Health Commission of Canada, 2012). The report recognizes the link between mental health and academic performance and recommends increasing comprehensive school health and post-secondary mental health initiatives that promote mental health for all students and include targeted prevention for those at risk (Mental Health Commission of Canada, 2012, recommendation 1.2.3). There are several unique advantages to offering mental health programming within the school setting. For example, class-wide programs may reach students who would not access formal children s mental health services (Kratochwill & Shernoff, 2003; Rohde et al., 1991). Further, since attendance and classroom expectations support course and homework completion, students are more likely than clinic-referred children to receive an intervention they require and less likely to discontinue treatment (Kazdin et. al., 1997; Kazdin, Mazurick, & Bass, 1993). Also, during class-wide social emotional learning instruction, higher risk students 1

5 may benefit from observing emotionally-skilled peers model good coping behaviour and attitudes (Lowry-Webster, Barrett, & Dadds, 2001). While school-based programming facilitates the early identification of difficulties when they first emerge (Middlebrooks & Audage, 2008), it also has the potential to maximize positive mental health development for all children, not only for those who are on a negative trajectory (Rowling & Weist, 2004). Finally, the implementation of empirically-supported mental health promotion and prevention programming in schools is associated with improved emotional and behaviour functioning (Greenberg, Domitrovich, & Bumbarger, 2001; Durlak et al., 2011), enhanced academic performance (Durlak et al, 2011), and cost savings (e.g., through reduction in referrals to special education) (Weist & Murray, 2007). There is growing momentum for school-based mental health in Canada and elsewhere Over the past decade, a number of provincial, national, and international initiatives have emerged in support of school mental health. These innovations include communities of practice (e.g., Canadian Association for School Health), mental health literacy initiatives (e.g., Trudeau & Watchorn, 2012), provincial coalitions (e.g., Stewart, Nyman, & Anderson, 2012), research projects (e.g., Cunningham et al., 2011; Slater, 2012), resources (e.g., teenmentalhealth.org), and discussion papers (Joint Consortium for School Health, 2010; Santor, Short, & Ferguson, 2009). International groups, such as the International Alliance for Child & Adolescent Mental Health & Schools and the US-Canada Alliance for School Mental Health serve to further inspire ideas and actions in this area. 2

6 PROJECT BACKGROUND In spite of considerable and increasing activity in school mental health in Canada over the past decade, there has been a lack of integration and common vision across initiatives. Recognizing this gap, the former Child and Youth Advisory Committee of the Mental Health Commission of Canada (MHCC) developed an initiative to understand what is known about effective school-based mental health and substance abuse programs and to discover the current context of Canadian school systems in this area. The focus for the Request for Proposals (RFP), issued in 2008, was on developing a broad framework and practical recommendations for school mental health and substance use services that would be applicable across geography and jurisdictions. Four key deliverables were identified: 1. A synthesis of the national and international literature related to frameworks and best practices in school mental health and substance use 2. An environmental scan of existing programs and services in Canada 3. A national survey of school districts related to their needs and practices 4. Knowledge translation and exchange activities, including an interactive national symposium for key stakeholders. The SBMHSA Consortium represents a cross-disciplinary, cross-sectoral, and geographically diverse set of leaders in research, policy, and practice. Stakeholders were invited to join the Consortium based on their recognized excellence in the field, content and/or methodological expertise, links to key networks and organizations, and commitment to working together for Canadian children and youth. The Consortium was organized into two main camps: Core Members and Key Stakeholder Members. Core members were leaders in the field with strong teams at their disposal. Key Stakeholder Members were affiliated with existing teams and who had links to specific constituencies (i.e., specific school boards, Aboriginal populations, cultural groups). Often, members provided a specialized skill set that enhanced the Consortium s capacity as a whole. Collectively, the Consortium represents a growing community of practice where new knowledge can be generated, existing knowledge can be synthesized, and best and emerging models of practice can be shared and further evolved. The Ontario Centre of Excellence for Child and Youth Mental Health was identified as the principal lead organization for the project and the work began in Four teams were created; Review, Scan, Survey, and Knowledge Translation and Exchange (KTE). The teams undertook work consistent with the main deliverables identified by the MHCC including: a review of literature on school mental health and substance use, a scan of best practices in Canadian schools, and a survey to school boards and schools seeking input on the state of child and youth mental health programs in Canada. The consortium s findings are aligned with the Evergreen Framework, a guide for child and youth mental health released by the MHCC in 2010, which emphasizes mental health promotion and prevention from intervention through to ongoing care. Results from the project also support the recommendations related 3

7 to promotion and prevention for children and youth in school in Changing Directions, Changing Lives: The Mental Health Strategy for Canada released by the MHCC in In summary, the SBMHSA Consortium project was designed to take stock of the various practices in Canada and growing evidence base, to determine national needs and priorities going forward. 4

8 KEY FINDINGS Research Synthesis The research synthesis summarized findings from 94 systematic reviews and meta-analyses conducted prior to January Rather than focusing on individual studies, this methodology collates high quality research from multiple studies devoted to the same topic. The team constructed inclusion criteria for high quality research and screened 363 reviews in the area of school-based mental health promotion, prevention, and intervention. The research synthesis was led by the Directions Evidence and Policy Research Group, with support from a SBMHSA Review Team and the wider Consortium. Mental Health Promotion An essential advantage of school programming is the opportunity to promote positive mental health of all students rather than focusing solely on those identified as having mental health problems. Community, school, and classroom efforts all create a culture of wellbeing and a sense of belonging for all students (Rowling, 2012). Specific programs are designed to promote student social skills and self-concept drawing upon a variety of techniques including: skills training, role playing, positive feedback, modeling and self-reflection. Overall, the review revealed encouraging results for mental health promotion activities, and the following conclusions are warranted: Universal programs can be effective in improving the wellbeing of children and youth. Social skills training or social emotional learning can be effective in bolstering student coping ability, and in addressing an array of emotional and behavioural problems. In addition, social emotional learning has been associated with enhanced academic achievement (Durlak et al., 2011). In general, programs are more effective when skills are taught systematically, in a class-wide manner, involve the whole school, and are implemented over more than one year. 5

9 Prevention Programs The synthesis indicated that the evidence on prevention of both internalizing problems (e.g., depressed mood, anxiety) and externalizing difficulties (e.g., conduct problems, aggression) is clear. There is compelling evidence for the use of behavioural and cognitive behavioural approaches in school mental health programs that focus on skill development and on identifying and challenging thoughts and beliefs that can lead to negative feelings and behaviours. The following conclusions are warranted: School-based behavioural and cognitive behavioural programs, designed to prevent problems like depressed mood and anxiety can be effective in reducing symptoms. For mood problems, the best approaches are skill-based and targeted (developing competencies and protective factors) rather than just delivering information at a universal level (psycho-educational). School-based behavioural and cognitive-behavioural programs, designed to prevent problems with aggression and conduct can be effective in reducing symptoms. For these externalizing behaviours, the best approaches focus on prosocial skill development, conflict resolution, anger management and stress management. Screening for mental health issues combined with effective early interventions can be a useful approach to prevention, but care must be taken to deal with the potential for stigmatization of students identified as having mental health issues. The review also yielded information to suggest that some preventive services have an inconsistent evidence base. Specifically: The literature on suicide prevention is complex and not yet conclusive. However, strategies such as school-based peer identification and response training (how to recognize risk and promote help-seeking), family support, appropriate skill development and professional training for mental health staff and educators appear to be helpful. Early identification and treatment of mental health problems are key components of suicide prevention. The results for school-based prevention of substance abuse are mixed. Approaches using interactive methods with dialogue and focusing on resistance education and life skills (decision making, assertiveness, problem-solving) can be effective. Other evidence points to peer involvement and collaborating with external contributors as helpful. 6

10 Intervention and Care There have been systematic clinical trials related to providing school-based intervention for a wide array of mental health disorders. The evidence available at this point in time warrants a number of conclusions: School-based behavioural and cognitive-behavioural interventions are more effective in treating internalizing problems than general counselling. For these disorders, the best approaches are skillbased and include elements such as social and problem solving skills, active coping and cognitive restructuring. Successful programs can be delivered to both individuals and groups. School-based behavioural and cognitive-behavioural programs are effective in treating problems with aggression and conduct. The most effective approaches for externalizing disorders focus on techniques such as recognizing stimuli that evoke negative responses, resisting aggressive responses and implementing alternative strategies, and skill-building in the areas of self-control, perspective-taking and conflict resolution. While group treatments have been shown to have positive effects, care has to be exercised to avoid contagion effects when congregating students with disruptive behaviours. The review did not yield consistent findings regarding substance use treatments at school. In summary, the review found clear evidence for the effectiveness of specific school-based strategies for mental health promotion, prevention, and treatment of internalizing and externalizing disorders. While there were conflicting opinions on effective school-based treatment for substance use problems, the review found clear evidence for specific school-based strategies for mental health promotion, prevention and treatment of internalizing and externalizing disorders. To ensure that the strategies are effective, the review points to a number of implementation considerations. For example, it clarified that programming in this area is not benign, and that selecting and implementing strategies must be done with care to ensure no harm to individuals or groups. An important element for success is the match between the program and the needs and resources of the setting. There is an insufficient body of evidence to provide direction for special populations; such as specific cultures, clinical needs, or a targeted age group. Also, to be effective, personnel need training and support to ensure that strategies are delivered with fidelity to the original program s methodology. Finally, programs require monitoring of process and outcomes to make sure they are achieving the desired results or require modification for the local context. Successful implementation requires dedicated leadership, proper preparation of the organization, and ongoing support for implementation, treatment integrity, and evaluation of program outcomes. 7

11 Scan of Nominated Best Practices The SBMHSA Consortium Scan was designed to gather information about school mental health and substance use programs, models, and initiatives currently implemented in Canada. The national scan was led by the Ontario Centre of Excellence for Child and Youth Mental Health, with support from a SBMHSA Scan Team and the wider Consortium. Scan Development, Recruitment and Administration Two sampling strategies were used for the SBMHSA scan. First, a link was distributed nationwide to Consortium members and their networks. The web link allowed individuals to identify and provide details of promising SBMHSA programs, models, or initiatives by completing an online nomination form. Second, project team members reviewed existing web-based databases and contacted additional key informants to identify and nominate promising programs from around the country. One or all of the following criteria needed to be met in order to be included in the scan: An established and emerging SBMHSA school linked or school-based program, model or initiative developed and currently being implemented in Canada, targeting students up to grade 12 and/or school staff; A Canadian implementation of SBMHSA international programs; Community and educational initiatives for aboriginal populations that involve physical, emotional, social or spiritual components. All contacts from nominated programs were invited to participate in an interview. About 200 invitations were sent out with 147 interviews completed from September 2010 to mid-january 2012 (73.5% response rate). One hour individual semi-structured telephone interviews were conducted, in English or French, by one of four members of the Scan team who were trained in the interview protocol. In addition to descriptive background information, the interview included 32 open-ended program related questions including: etiology of program adoption, focus, approach, target audience, level of partnership involvement, challenges and enablers associated with implementation, as well level of program evaluation. Following the interview, each participant was given an opportunity to review and validate the summary of their responses. Several respondents also sent a variety of resources such as manuals, pamphlets, and reviews to supply an additional source of information on their programs. All of these materials were archived by program. Scan Demographics Programs from all Canadian provinces and territories were represented in the scan with the largest number of respondents being from the province of Ontario (n=61). For the purpose of the scan, school-based programs were defined as programs being implemented within the school setting and/or built into the curriculum. School-linked programs were also nominated, and included referrals from schools to outside agencies or community agencies delivering presentations and/or programs within the school environment. The final sample contained 87 school-based programs and 58 school-linked programs. In total there were nine French language programs in the final sample. With respect to target area, 51% of the sample focused on mental health programming, 17% on substance abuse, and 32% targeted both areas. 8

12 Scan Findings Results from the SBMHSA Scan were analyzed across programs for an overall picture of the Canadian context. Main findings across programs include: The vast majority of programs were developed/implemented based on an identified need at the school and/or community level (75%). More programs served students in grade 9-12 relative to those in younger grades. Programs tended to focus primarily on one of three intended goals; 1) risk behaviour prevention (50%), 2) prosocial skill development (41%) and 3) mental health literacy (37%). Most programs in the scan were English, with some designed for special populations (e.g., specific culture, clinical needs, or targeted age group). Key barriers to implementation and sustainability include: funding, buy-in, financial barriers, time and capacity. Key enablers include: partnerships, capacity, an identified need, and leadership. Partnerships were described as key for program implementation; however, youth and parent/family involvement in program design/implementation was limited. Less than half of the respondents indicated that their programs were subject to evaluation with great discrepancy as to what constituted a formal evaluation. Further, overall there was a weak link to the evidence base in this area. In summary, the SBMHSA Scan revealed that there are many exciting, relevant, and important mental health and substance use programs and practices in being implemented in Canadian schools. At the same time, programs nominated through the Scan cover a range of target problems and were frequently created in response to an identified need in boards. This has resulted in a patchwork of tested and untested school mental health initiatives across the country. In an attempt to begin to organize this work, the SBMHSA Consortium has compiled a searchable database through which program information has been synthesized and shared. This site is organized into service categories that align with the Evergreen Framework (i.e., mental health promotion, prevention, intervention and ongoing care, capacity building, service delivery models). Visitors can search by service categories to learn about programs, or can view by specific focus topics (i.e., social emotional learning, internalizing problems, externalizing problems, substance use, suicide prevention, crisis response, stigma reduction, mental health literacy, screening/early identification, school board processes), target audiences (i.e., educators, parents/ guardians/ families, elementary students, 9

13 secondary students, mental health professionals, pre-school), or special populations (autism/pdd/developmental delay, economically disadvantaged, First Nations, Métis, Inuit, immigrant/refugee, French language, gender). Programs can also be displayed on a map, by province. When a particular program is selected, visitors can view a brief summary document and can link to additional resources and related sites. Contact information is provided so that userscan connect with individuals who are knowledgeable about the program and its implementation in a Canadian school board. The SBMHSA Scan Database is currently housed here: There is an accompanying document on the site that highlights Canadian programs nominated that align well with the evidence base summarized in the SBMHSA Review. 10

14 National Survey The national SBMHSA Survey was designed to describe the status of school mental health and substance use service delivery in Canadian schools and school boards. It included items related to student mental health needs, available programs and services, training approaches, and implementation issues. Survey development, administration, analysis, and reporting was led by Directions Evidence and Policy Research Group, with support from a SBMHSA Survey Team and the wider consortium. Survey Development, Recruitment, and Administration Two versions of the survey were created; one collected information at the district level, and a second survey collected information from school level respondents. Draft versions were piloted with 17 respondents in four different provinces. Final surveys were prepared for online administration in both English and French. To recruit participants, an invitation was sent to 383 school boards across Canada, via directors and superintendents of education in May Directors and superintendents were asked to send the link to principals requesting them to forward the link to the individual in their school most knowledgeable about school mental health needs and services. Directors were also asked to identify one representative to complete a survey on behalf of the school board. Those who agreed to participate reviewed an on-line consent form and completed items via survey software at their convenience during the survey period. At the end of June the surveys were closed and the responses were tallied. Because the late spring period has many competing demands for schools, the survey was re-opened in the fall of Between October and December three reminders were sent out, and a research assistant made personal contact with all English speaking boards. The surveys remained open until late December Survey Demographics Representatives from a total of 177 school districts, including 643 schools completed the survey. All provinces and territories were represented, but most respondents were from Ontario, Alberta, British Columbia, and Manitoba. Communities varied by size and rural/urban composition. Most individuals completed the English version of the survey (>90%). The majority of those representing schools were from the elementary panel (70%). As well, 40-50% of respondents indicated that they had more than ten years of experience in school mental health. 11

15 Survey Findings The survey yielded information about the status of school mental health in Canada, in many specific areas. A few key highlights are summarized below: Approximately 85% of board-level respondents indicated they were concerned or very concerned about student mental health and/or substance use. Fewer school-level respondents expressed this level of concern (65%). Over 80% of respondents indicated that there are unmet student mental health and/or substance use needs in their board or school. At a board-level, respondents indicated that problems with attention, learning, substance use, anxiety, and bullying/social relationships were the most common in their schools. School personnel echoed these as primary concerns, but ranked anxiety and depression as being more common than substance use. Research suggests there are a number of system-level conditions that are critical for effective school mental health to flourish (Weist et al., 2005). On the survey, respondents indicated that some of these conditions are in place, such as using a team approach to service delivery that includes the perspectives of both mental health professionals and educators (>90% of respondents), but system-level gaps were also noted (e.g., lack of a clear protocol and agreements defining the pathway to service in their community, insufficient professional development). Boards and schools were asked to report on their stage of implementation for each service category in school mental health, from mental health promotion to prevention to intervention and ongoing care. Few boards or schools provide coordinated, evidence-based services across the continuum of care. Most indicated that they were at a level of partial implementation with respect to mental health promotion and prevention programming. More board-level respondents reported being at full implementation or sustainability for intervention and ongoing care. Respondents indicated that, in this area, special programs and individual/group counseling delivered by an educator were more prevalent than the use of evidence-based therapy provided by a trained mental health professional. The most commonly identified challenges to implementation were: (1) insufficient funding, services, staff to meet the demand; (2) a need for parent awareness, engagement; (3) a need for more prevention / promotion programming; (4) a need for more rofessional development; and (5) stigma. In summary, there were few differences in perspective across survey versions, although needs around training, collaboration, and implementation supports were particularly highlighted at the school level. The consensus is that school boards in Canada do not yet have the organizational conditions in place to deliver coordinated, evidence-based strategies across the continuum of care. While district and school teams are growing, and boards are beginning to develop policies, needed infrastructure for effective school mental health is lacking (e.g., protocols for decision-making, systematic training, role clarity). Respondents indicated that the emphasis in boards continues to be on intervention services for high needs students, rather than on mental health promotion and prevention. The full continuum of care is not being addressed in a proactive, even manner. The field is calling for more professional development for educators, particularly in relation to mental health promotion and prevention, recognizing signs and symptoms of mental health problems, and engaging families. 12

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